UNIVERSITY ORTHOPEDICS OF NEW YORK, PLLC
Steven Touliopoulos, M.D.
Charles A. DeMarco, M.D.
ORTHOPEDIC SURGEON
SPORTS MEDICINE
Board Certified
ORTHOPEDIC SURGEON
SPORTS MEDICINE
Board Certified
Kioomars Moosazadeh, M.D.
Barry Katzman, M.D.
John Vlattas, M.D.
ORTHOPEDIC SURGEON
PHYSICAL MEDICINE &
REHABILITATION
Board Certified
HAND/MICROVASCULAR SURGERY
SPORTS MEDICINE
Board Certified
Erica Papathomas, D.P.M.
PHYSICAL MEDICINE & REHABILITATION
Board Certified
PODIATRY
Kenneth Vitale, M.D.
PHYSICAL MEDICINE & REHABILITATION
Board Certified
PATIENT: NANCY ALVAREZ
DATE: August 20, 2012
INITIAL EVALUATION:
This is an initial evaluation of a 40-year-old female who was involved in a passenger motor vehicle
accident that occurred on 07/19/2012. She did not initially go the hospital and followed in the hospital
the following day. In the accident she sustained injuries to her cervical, thoracic, and lumbar spines,
bilateral shoulders, and right knee. She is complaining of intermittent paresthesias to both her upper and
lower extremities with increased paresthesias to the first, second, and third digits in bilateral upper
extremities. She has difficulty raising either arm above shoulder level. She has difficulty with overhead
activities. She has difficulty with repetitive activities. With respect to right knee she has frequent
buckling and giving out. She is unable to walk for extended period of time. She has difficulty
ambulating up and downstairs. She has difficulty ambulating on uneven surfaces. With respect to lower
extremity she is having intermittent paresthesias mostly to her calf area and big toe. She has been doing
physical therapy since the accident with only mild and temporary results. She takes Motrin on a p.r.n.
basis for pain. Although pain level is approximately 8-9/10 and increases with activity. All activities of
daily living have been adversely affected due to injuries sustained in the accident.
PAST MEDICAL HISTORY: See attached.
PAST SURGICAL HISTORY: See attached.
DRUG ALLERGIES: See attached.
PHYSICAL EXAMINATION: The patient is awake, alert, and oriented x3. Vital signs are stable.
Examination of cervical spine reveals paraspinal musculature, tenderness, and spasm. Restricted range
of motion in all planes. Spurling’s sign produced discomfort bilaterally. Examination of thoracic and
lumbar spine reveal paraspinal musculature, tenderness, and spasm. Restricted range of motion in all
planes. Lower extremity tension signs are positive bilaterally. Examination of bilateral upper extremity
shoulders reveal tenderness along rhomboid and trapezius musculature. Restricted range of motion
secondary to pain. Forward flexion is 120 degrees, abduction is 100 degrees, external rotation is 40
degrees, and internal rotation is to L5. Rotator cuff strength significantly diminished in all planes.
Hawkins and Neer’s impingement signs are positive. Apprehension and relocation tests are positive.
The patient does have decrease sensation in first, second, and third digit palmar side. Examination of
right knee reveals restricted range of motion 0-110 degrees. There is mild persistent effusion. Anterior
drawer and Lachman reveal vague endpoints. Meniscal signs produce discomfort. Pivot-shift test is
positive. There is no varus, valgus or posterior instability. Calves are soft and nontender bilaterally.
Astoria
23-18 31st Street, Suite 210
Astoria, N.Y. 11105
718-777-1885
Fax: 718-777-9613
Manhattan
155 Fifth Avenue, 2nd Floor
New York, NY 10010
212-924-6644
Fax: 212-924-9442
Bronx
1335 Westchester Avenue
Bronx, NY 10461
718-409-0050
Fax: 718-777-9613
UNIVERSITY ORTHOPEDICS OF NEW YORK, PLLC
Steven Touliopoulos, M.D.
Charles A. DeMarco, M.D.
ORTHOPEDIC SURGEON
SPORTS MEDICINE
Board Certified
ORTHOPEDIC SURGEON
SPORTS MEDICINE
Board Certified
Kioomars Moosazadeh, M.D.
Barry Katzman, M.D.
John Vlattas, M.D.
ORTHOPEDIC SURGEON
PHYSICAL MEDICINE &
REHABILITATION
Board Certified
HAND/MICROVASCULAR SURGERY
SPORTS MEDICINE
Board Certified
Erica Papathomas, D.P.M.
PHYSICAL MEDICINE & REHABILITATION
Board Certified
PODIATRY
Kenneth Vitale, M.D.
PHYSICAL MEDICINE & REHABILITATION
Board Certified
August 20, 2012
RE: Nancy Alvarez
Page 2
ASSESSMENT: This is a 40-year-old female who was involved in a passenger motor vehicle accident
that occurred on 07/19/2012 resulting in:
1. Cervical, thoracic, and lumbar spine strain, rule out radiculopathy, rule out disc herniation.
2. Bilateral shoulder posttraumatic impingement syndrome and instability, rule out rotator cuff tear,
rule out labral tear.
3. Right knee posttraumatic occult ACL deficiency, rule out meniscus tear, rule out chondral injury.
PLAN: The treatment options were discussed with the patient. At this time, further evaluation of injury
sustained in the accident in the form of MRI is warranted. I am recommending for MRI of the cervical
spine, lumbar spine, and right knee. In the interim, the patient may continue with physical therapy,
anti-inflammatory medication, and also neurology consultation for paresthesias to upper and lower
extremities. She is to follow up with us in approximately 3-4 weeks once MRIs completed. All activity
modifications and restrictions were explained to the patient.
ELECTRONICALLY SIGNED BY:
Steven Touliopoulos, M.D. (08/20/2012)
Andrew Cruz, RPA (08/21/2012)
Steven Touliopoulos, M.D.
Andrew Cruz, RPA
ST/mrs
Astoria
23-18 31st Street, Suite 210
Astoria, N.Y. 11105
718-777-1885
Fax: 718-777-9613
Manhattan
155 Fifth Avenue, 2nd Floor
New York, NY 10010
212-924-6644
Fax: 212-924-9442
Bronx
1335 Westchester Avenue
Bronx, NY 10461
718-409-0050
Fax: 718-777-9613